The dark side of transurethral access for LUTS/BPH surgery: a narrative review

Abstract

The transurethral route is the access of choice for benign prostatic hyperplasia (BPH) surgical treatment. Transurethral resection of the prostate (TURP) has been the gold standard in surgical intervention for BPH; however, the advent of novel surgical techniques and the exploration of new energy sources in recent decades have seen this primacy contested. Nevertheless, the transurethral route harbors numerous challenges and pitfalls that can pose significant risks even for the most experienced endoscopic urologists. Complications associated with transurethral access are well documented yet often underestimated by endoscopic surgeons, primarily because the pathological conditions arising from transurethral surgery typically fall within the realm of those specializing in genitourinary reconstructive surgery. This narrative review describes and critically discusses the specific pitfalls associated with transurethral surgery for BPH. Urethral strictures, transient or permanent postoperative incontinence, reintervention, and de novo/persistent lower urinary tract symptoms (LUTS) represent the main complications of transurethral treatments for BPH. These problems still stand as the foremost challenge for all endoscopists despite recent technological advancements. The use of increasingly miniaturized instruments, more mindful energy application, sphincter-sparing enucleation techniques, and the advent of so-called minimally invasive surgical techniques (MISTs) all contribute to a more conscious and anatomically respectful transurethral approach. An endoscopic transvesical suprapubic access may be another alternative strategy to minimize the complications of transurethral route in the future.

INTRODUCTION

The transurethral surgery has been the treatment of choice for benign prostatic hyperplasia (BPH) for almost a century now, establishing the resectoscope as the tool of choice for urological surgeons.1 Since 1926, Maximilian Stern proposed a revolutionary access through the urethra to treat “obstruction at the vesical entrance”.1 Stern’s foresight in revolutionizing BPH treatment, thereby ushering in the transurethral surgery era, was monumental. While transurethral resection of the prostate (TURP) has enjoyed longstanding primacy as the go-to surgical intervention for BPH, the advent of novel surgical techniques and the exploration of new energy sources in recent decades have seen this primacy contested.1,2 Different types of laser technology for the treatment for BPH have been used in the past two decades and have garnered strong support from international guidelines.2 Notably, the newest technologies share the urethral route as the preferred access way as a minimally invasive option.2 However, the transurethral access harbors numerous challenges and pitfalls that can pose significant risks even for the most experienced endoscopic surgeons.3 Complications associated with transurethral access are well documented yet often underestimated by endoscopic urologists, primarily because the pathological conditions arising from transurethral surgery typically fall within the realm of those specializing in genitourinary reconstructive surgery.3,4 Anatomical structures such as the urethral mucosa, the external urethral sphincter, and the bladder neck can be compromised during transurethral procedures, given their delicate nature.3,4 Urethral strictures, transient or permanent postoperative incontinence, and de novo/persistent lower urinary tract symptoms (LUTS) represent the main concerns of this type of surgery.3,4 Although these complications occur at relatively low percentages, they affect a significant number of patients due to the global prevalence of BPH techniques.3,4 These problems still stand as the foremost challenge for all endoscopists despite recent technological advancements.

This narrative review aims to describe and critically discuss the specific pitfalls associated with transurethral surgery for BPH.

A narrative, non-systematic literature search was performed to identify key studies on transurethral access for LUTS/BPH surgery. The bibliographic databases searched included PubMed, Medline, and Google Scholar.

Search terms included, but were not limited to “LUTS/BPH surgery”, “transurethral”, “complication”, “reintervention”, “urethral stenosis”, and “urinary incontinence”, with relevant MeSH terms. All article types were considered. Emphasis was placed on studies published in the last 10 years (from 2015 to 2025). The findings have been presented in a narrative format and grouped according to the following key areas identified: urinary incontinence, urethral strictures, bladder neck stenosis, and persistent/de novo post-operative LUTS and reintervention.

URINARY INCONTINENCE

Incidence and risk factors

Urinary incontinence (UI) is one of the most bothersome and frequent complications following endoscopic surgical procedures for BPH.3,5,6,7 Despite advancements in surgical techniques and energy sources, UI remains a persistent issue with varying incidence rates across studies.3,5,6,7 A systematic review and meta-analysis by Castellani et al.8 examined UI rates following different transurethral surgical techniques, including ablative procedures, enucleation, monopolar TURP (M-TURP), and bipolar TURP (B-TURP). Their findings revealed transient stress urinary incontinence (SUI) rates of 4.6%, 6.0%, 3.0%, and 2.4% with persistent SUI occurring in 1.1%, 1.7%, 1.7%, and 1.0% of cases, respectively.8 Additionally, transient urgency urinary incontinence (UUI) was reported at 2.0%, 7.3%, 4.4%, and 2.8%, respectively, with persistent UUI occurring in 2.2% of patients after M-TURP.8 Transient mixed urinary incontinence (MUI) rates were found to be 5.1%, 0.8%, 5.4%, and 0.9% for ablative procedures, enucleation, M-TURP, and B-TURP, respectively, while persistent MUI was recorded in 3.1% of patients after ablation and 4.8% after M-TURP.8 Minimally invasive surgical techniques (MISTs), such as Rezum, AquaBeam, and UroLift, have shown promising results. While long-term efficacy data are still limited, these techniques are associated with a significantly lower risk of transient and persistent UI, with rates below 2%.9,10,11

Mechanistic insight

The urethral sphincter complex, consisting of the internal smooth muscle sphincter and the external striated rhabdosphincter, plays a crucial role in urinary continence.12 The rhabdosphincter is most prominent around the membranous urethra and diminishes toward the bladder, while the internal sphincter is strongest at the bladder neck and narrows along the urethral path.12 The internal sphincter primarily maintains continence at rest, whereas the rhabdosphincter is responsible for active continence under stress and supports antegrade semen movement.12 During endoscopic resection or laser procedures, mechanical stress, both linear and angular, on the rhabdosphincter is a significant contributor to UI.12 TURP, the gold standard for BPH surgery, poses risks due to mechanical traction from the resectoscope and repeated instrument passage through the sphincter, particularly with devices larger than 24 Ch.12 Laser enucleation presents an even higher risk of transient SUI due to uncontrolled retrograde force in the absence of adequate sphincter relaxation.12

Technique-specific impacts

Montorsi et al.13 compared holmium laser enucleation of the prostate (HoLEP) with TURP, finding that 1 month postoperatively, 44% of HoLEP patients experienced UUI compared to 38.6% in the TURP group. A meta-analysis by Hout et al.6 showed that photovaporization of the prostate (PVP) and open/robotic simple prostatectomy had the highest UI rates. SUI was most prevalent within the first 3 months after HoLEP (4%), followed by open/robotic prostatectomy at 3–6 months (3%).6 UUI rates were highest in patients undergoing thulium laser procedures (10%) in the first 3 months, with HoLEP showing 1%–3% higher UI incidence beyond 3 months. While most cases of SUI resolve within 1 year, its variable incidence (1.4% to 44%) remains a concern for laser treatments.14,15 Techniques like holmium laser ablation of the prostate (HoLAP) and PVP, which have lower learning curves and reduced SUI risk, are becoming more popular.16,17

Among MISTs, waterjet dissection of the prostatic adenoma (AquaBeam; PROCEPT BioRobotics Corporation, San Jose, CA, USA) has a reported UI rate of 0.99%.18 The Rezum technique has shown promising short-term results, although limited UI data are available.19,20 In a randomized controlled trial (RCT) of 200 patients, Sheba et al.21 compared TURP with UroLift. Patients treated with UroLift had shorter hospital stays and better erectile and ejaculatory function. No SUI was detected in the UroLift group, whereas 6.7% of TURP patients experienced SUI.21 However, UroLift patients showed less improvement in International Prostate Symptom Score (IPSS) compared to the TURP cohort21 (Table 1).

Table 1.

Studies on transurethral lower urinary tract symptoms/benign prostate hyperplasia surgery, focusing on postoperative urinary incontinence

Study	Brief description of the study	Intervention	Comparison	Key findings (focus on urinary incontinence)
Cornu et al.3 2015	Meta-analysis of functional outcomes and complications of transurethral procedures for BPH	TURP, HoLEP, PVP, and others	Various approaches	B-TURP, HoLEP, and PVP have shown efficacy outcomes comparable with M-TURP but with reduced complication rate and shorter hospital stay. Continence rate does not differ significantly across the techniques
Licari et al.4 2024	Postoperative incontinence after BPH surgery: a retrospective database analysis	Various approaches	-	Persistent UI was 4%.UUI rates varied between 0.62% (PAE) and 2.71% (PVP), SUI ranged between 0.04% (PAE) and 2.75% (Lap/Rob SP), while MUI ranged between 0.11% (PAE) and 1.17% (HoLEP/ThuLEP). On multivariable analysis, HoLEP/ThuLEP (OR: 1.612; P<0.001), PVP (OR: 1.164; P<0.001), open SP (OR: 1.424; P<0.001), and laparoscopic/robotic SP (OR: 1.667; P<0.01) showed significant higher likelihood of UI compared to TURP. PUL (OR: 0.604; P<0.001), Rezum (OR: 0.661; P<0.001), Aquablation (OR: 0.434; P<0.01), and PAE (OR: 0.178; P<0.001) were associated with lower likelihood of UI
Vavassori et al.5 2008	3-year outcomes of HoLEP with morcellation	HoLEP	-	IPSS decreased from 24 to 1 at 3 years. Qmax improved from 9 ml s−1 to 25.1 ml s−1. Reoperation rate was 2.7%. Transient SUI: 7.3%, mainly resolved in 3 months. Persistent SUI at 3 years: 0.6%
Hout et al.6 2022	Postoperative incontinence after BPH enucleation surgery: meta-analysis	Various approaches	-	Although not statistically significant, the incidence of UI was higher (15%) at short-term with GreenLEP and SP and higher (4%) at intermediate-term with HoLEP. SUI was more prevalent at short-term with HoLEP (4%) and at intermediate-term with SP (3%; 95% CI: 1–14). UUI was higher in the ThuLEP (10%, 95% CI: 7–16).Increased age, surgery time, laser time, and prostate size up to 80 ml were associated with higher UI
Castellani et al.8 2022	Postoperative incontinence after BPH surgery: meta-analysis	Various approaches	-	Ablation, enucleation, and TURP have an impact on all forms of incontinence, but this is transient in most cases with no difference between the groups, except for MUI, which was higher after enucleation versus M-TURP (OR: 3.26; P=0.003)
McVary et al.9 2019	Rezum therapy: 4-year outcomes	Rezum	Placebo	IPSS reduced by 47%, and Qmax improved by 50%. No effect on erectile function (IIEF unchanged). Retreatment rate: 4.4% at 4 years. Urinary incontinence: 1.5% at 12 months
Gilling et al.10 2020	Aquablation vs TURP: 3-year results	Aquablation	TURP	After 3 years, retreatment rates were 4.3% in the Aquablation group and 1.5% in the TURP arm. Improvements in IPSS and Qmax were statistically similar across groups. Urinary urgency/UI at 3 months: 6.9% (Aquablation) vs 9.2% (TURP)
Kim et al.11 2020	Prostatic urethral lift in an Asian population	UroLift	-	Mean IPSS, QOL, and Qmax improved to 41%, 60%, and 32% by 12 months (P<0.001), respectively, from baseline. No observed erectile dysfunction and UI cases. No one required surgical retreatment at 1 year
Montorsi et al.13 2008	HoLEP vs TURP: randomized trial	HoLEP	TURP	Mean catheterization time was 31 h for HoLEP group versus 57 h for TURP. Transient (at 1 month) UI was more common in the HoLEP group (44% vs 38.6%), although at the 12-month follow-up, UI rates were comparable (1.7% vs 2.2%) across the groups
Fallara et al.16 2021	10-year follow-up after HoLEP	HoLEP	-	75% of patients still satisfied at 10 years. At 10 years, 5.7% reported UI, and 4.7% underwent redo surgery throughout the follow-up period due to either bladder neck contracture or urethral stricture
Kiba et al.17 2020	PVP vs B-TUEP: randomized trial	PVP	B-TUEP	Improvements of subjective and objective parameters were superior after B-TUEP than after PVP. SUI was more frequently observed in the B-TUEP group (5% vs 2%), while urethral stricture was more common in the PVP group (16% vs 0)
Reale et al.18 2019	Aquablation for BPH	Aquablation	-	Functional outcomes comparable to TURP. No impact on erectile function (IIEF-5 unchanged). Lower rate of retrograde ejaculation.Retreatment rate at 3 years: 3.2%. Urinary incontinence at 12 months: 0.9%
Campobasso et al.19 2023	Urinary and sexual outcomes after Rezum	Rezum	-	UI rate was 2.2%. Retreatment rate at 1 year was 1.5%. Optimal urinary outcomes (≥50% improvement in the IPSS <7, improvement in peak flow ≥50%, and/or more than 15 ml s−1) were achieved only in 52.9% of the patients. The preoperative antegrade ejaculation rate was 56.5%, and after the procedure, it increased to 78.2%
Siena et al.20 2021	Early results of Rezum in Italy	Rezum	-	Patients reported a significantly decrease of IPSS from baseline at first (21.5 vs 7.5; P=0.001), third (21.5 vs 4.2; P<0.0001), and sixth (21.5 vs 4.4; P<0.0001) months after surgery. Retreatment rate at 1 year: 2.2%. No de novo postoperative incontinence was reported
Sheba et al.21 2025	UroLift vs TURP: randomized trial	UroLift	TURP	TURP showed greater IPSS improvement than UroLift (P<0.001). UI occurred in 10% of TURP patients but none in UroLift. At 4 years, retreatment rates favored TURP (5% vs 40%)
Saitta et al.22 2019	HoLEP with early apical release: results	HoLEP with early apical release	-	Effective and safe technique. SUI rate was 5.8%, 1.5%, and 0.7% at 1 month, 3 months, and 6 months post-operation, respectively
Tunc et al.23 2021	“Omega Sign” HoLEP technique	HoLEP	HoLEP with “Omega Sign”	SUI rates were significantly lower in the “Omega group” after catheter removal (3% vs 6%; P=0.007) and at the 1st month (1% vs 4%; P=0.03)
Taha et al.24 2023	Mini-HoLEP vs HoLEP	Mini-HoLEP	HoLEP	Similar effectiveness and operative time. Shorter period of postoperative SUI for the MiLEP group compared to the HoLEP group: 15% vs 42% (P=0.01) at 1 month, 8% vs 14% (P=0.07) at 2 months, and 0 vs 0.3% (P=1) at 3 months, respectively
Alves et al.25 2024	MiLEP	MiLEP	-	Urinary continence rate was ≥95% at 1 week after the procedure and 99% in the 1st month. None experienced UI after 6 months.Retreatment rate: 1.47% at 6 months

HoLEP: holmium laser enucleation of the prostate; TURP: transurethral resection of the prostate; PVP: photovaporization of the prostate; B-TURP: bipolar TURP; M-TURP: monopolar TURP; UI: urinary incontinence; MUI: mixed UI; SUI: stress UI; UUI: urgence UI; ThuLEP: thulium laser enucleation of the prostate; GreenLEP: GreenLight laser enucleation of the prostate; PAE: prostate artery embolization; SP: simple prostatectomy; IPSS: International Prostate Symptoms Score; IIEF: International Index of Erectile Function; MiLEP: minimally invasive laser enucleation; TUEP: transurethral enucleation of the prostate; -: none; OR: odds ratio; CI: confidence interval; Q_max: the maximum urinary flow rate

Risk mitigation strategies

Efforts to minimize UI after transurethral surgery focus on optimizing surgical techniques, refining energy application, and improving surgeon training. Key strategies include reducing mechanical trauma, controlled energy application, adequate surgeon training and experience, and correct patient selection and counseling.

Techniques that minimize sphincter manipulation may lower the UI rates.22,23 New HoLEP techniques incorporating early apical release aim to protect the external sphincter, reducing postoperative incontinence.22,23 Miniaturized HoLEP (MiLEP, 22 Ch) has demonstrated better continence outcomes than standard HoLEP with a 26 Ch resectoscope.24,25 Taha et al.24 reported SUI rates of 15% and 42% at 1 month, 8% and 14% at 2 months, and 0 and 0.3% at 3 months for MiLEP and HoLEP, respectively (all P = 0.01). A novel approach developed by Bucca et al.,26 known as suprapubic transvesical resection of the prostate (STARP), aims to preserve the external sphincter and functional urethra. This technique, utilizing a mini transvesical access and bipolar resection with a new 42 Ch resectoscope, has shown 0 transient and permanent UI post-surgery in preliminary studies.26 Adjusting laser settings to avoid excessive thermal damage may help preserve sphincter function.14,15,16 Standardized training programs emphasizing sphincter preservation may improve surgical outcomes and reduce UI incidence.7,14,15 Lastly, identifying high-risk patients (e.g., those with pre-existing sphincter dysfunction or large prostates) allows for tailored surgical planning. Preoperative counseling regarding UI risks and resolution timelines can enhance patient satisfaction.3

Summary

UI remains a significant complication following transurethral BPH surgery, influenced by surgical technique, procedure duration, and surgeon experience. TURP, HoLEP, and laser-based techniques exhibit varying risks of transient and persistent UI, with incidence rates ranging from 1.4% to 44%. MISTs demonstrate lower UI rates due to their sphincter-preserving properties. Emerging techniques such as STARP show promise in reducing UI while maintaining surgical efficacy, though further studies are needed to confirm preliminary data. Advancements in surgical techniques and enhanced surgeon training will be crucial in minimizing UI post-BPH surgery.

URETHRAL STRICTURES

Incidence and risk factors

The landscape of surgical interventions for symptomatic BPH has evolved remarkably over recent decades.27,28 Despite this evolution and improvement in surgical technologies and techniques, urethral stricture (US) remains a significant late complication that impacts patient’s quality of life and presents a management challenge for urologists.29

The incidence of US disease after BPH procedures has been variably reported, ranging from 1% to 10%, and has not declined over the years.30,31 BPH surgery still represents the most common cause of iatrogenic US, accounting for up to 41% of all cases.29,30,31,32 The inconsistency in reported rates could be due to various surgical methods analyzed, the instruments used, patient characteristics, and how urethral strictures are defined in different studies.29,30,31,32 Moreover, this condition usually develops 6–12 months following surgery, making it necessary for study designs to include an adequate follow-up period to capture this long-term complication.29,30,31,32

Several known, and therefore predictable, etiological factors contribute to the development of iatrogenic US.33,34 Instrument size in transurethral techniques has been identified as one of the primary factors contributing to this process.35 Other factors include prolonged ischemic damage due to repeated passage of surgical instruments, thermal injury to the urethral mucosa from electrocautery and lasers, extended surgical durations, postoperative urinary tract infections (UTIs), and prolonged catheterization time.34,35,36,37,38,39,40

Mechanistic insight

The pathophysiological processes that lead to US formation post-BPH surgery involve dysregulated wound healing. The delicate balance between extracellular matrix production and degradation is disrupted, leading to excessive collagen deposition and fibrosis.33,34 The instrument size in transurethral techniques has been identified as one of the primary factors contributing to this process.35 Mechanical urethral trauma, tissue compression, and prolonged ischemic damage initiate inflammatory responses, leading to scar tissue formation and subsequent stricture.35 Günes et al.35 reported a statistically significant increase in the incidence of bulbar strictures in patients treated with a 26-Ch resectoscope compared to a 24-Ch resectoscope (P = 0.018). The rationale behind the miniaturization of surgical instruments, as introduced by MiLEP using a 22-Ch and 18.5-Ch endoscope, aims to reduce urethral injury while maintaining intraoperative effectiveness.36

Thermal injury is another critical risk factor, as bipolar TURP has been associated with a higher incidence of US (6.1% to 8.3%) compared to monopolar TURP (1.9% to 4.2%).38 This increased risk might be linked to the greater cutting current used in bipolar methods, 270 watts versus 175 watts for monopolar resections. However, prospective randomized trials, such as that by Falahatkar et al.,39 challenge this notion by reporting only a 2% stricture rate despite using higher energy levels (280 watts). The conflicting evidence highlights the need for further studies to determine the role of energy type and intensity in urethral strictures. Lastly, the risk of US is further exacerbated in the perioperative period by the presence of foreign bodies, such as a urinary catheter. This risk is particularly associated with catheter size and prolonged catheterization, which can cause irritation and increased inflammation of the urethral lining.40

Technique-specific impacts

The clinical significance of the US following novel surgical techniques remains under investigation.41 Various studies have assessed the complication rates of laser enucleation (HoLEP/ThuLEP) and PVP, given their increasing use.41,42,43 The incidence of urethral strictures after TURP (ranging from 2.2% to 9.8%) is comparable to HoLEP/ThuLEP and PVP procedures (1.2% to 7.3%).2,44 Elsaqa et al.44 found no significant difference in post-operative US rates between TURP (7.9%) and HoLEP (4.7%; P = 0.34). Given that these techniques employ instruments of similar diameters, the findings suggest that instrument size might be a more critical factor in US development than the surgical technique itself.

Conversely, MISTs, such as Prostatic Urethral Lift (UroLift; Teleflex Incorporated, Wayne, PA, USA), Robotic Waterjet Treatment (Aquablation; PROCEPT BioRobotics Corporation, San Jose, CA, USA), and Water Vapor Thermal Therapy (Rezum; Boston Scientific, Marlborough, MA, USA), demonstrate lower US rates.45,46 The reduced operative time and minimal urethral manipulation characteristic of these procedures, along with the absence of energy-induced urethral damage, likely contribute to this outcome.45,46 However, MISTs tend to have higher surgical retreatment rates, which may contribute to long-term urethral damage47 (Table 2).

Table 2.

Studies on transurethral lower urinary tract symptoms/benign prostate hyperplasia surgery, focusing on postoperative urethral strictures

Study	Brief description of the study	Intervention	Comparison	Key findings (focus on urethral strictures)
Chen et al.30 2016	Non-systematic review of studies on urethral strictures following prostate surgery	Various	-	US incidences were as follows: TURP (1.7%–11.7%), HoLEP (1.4%–4.4%), and PVP (0–4.4%)
Gür et al.33 2021	Risk factors for early urethral strictures after TURP	TURP	-	US detected in 3.9% of patients post-TURP. Prolonged operative time and high comorbidity burden significantly increased stricture risk
Günes et al.35 2015	Role of resectoscope size in urethral stricture formation post-TURP	TURP 26 Ch	TURP 24 Ch	Larger resectoscope size associated with increased risk for bulbar US (11.4% vs 2.9%; P=0.018). No difference for meatal US (2.9% vs 5.7%; P=0.386)
Autorino et al.37 2009	4-year outcomes in a prospective clinical trial between M-TURP and B-TURP	M-TURP	B-TURP	No difference for bulbar US (6.4% vs 3.1%; P=0.6)
Seckiner et al.38 2006	1-year outcomes in a prospective clinical trial between M-TURP and B-TURP	M-TURP	B-TURP	Similar incidence of US across the groups
Falahatkar et al.39 2014	Prospective clinical trial between TUVP and B-TURP (3 months of follow-up)	TUVP	B-TURP	TUVP group had better functional outcomes and significantly lower mean values of operative time, hospital stay, catheterization period, irrigation fluid volume, and serum hemoglobin, creatinine, and sodium and potassium changes compared with the TURP group. No significant differences were seen regarding US (TUVP=0; TURP=2%; P=1.00)
Tao et al.40 2016	Analysis of risk factors for urethral stricture and bladder neck contracture after TURP	TURP	-	Lower resection speed, intraoperative urethral mucosa rupture, and postoperative continuous infection were associated with a higher risk of US
Pirola et al.41 2022	Systematic review and meta-analysis of urethral strictures following endoscopic prostate surgery	TURP, HoLEP, and PVP	-	Pooled incidence of US was 1.7% after enucleation, 2.1% after ablation, 3.8% after M-TURP, and 2.1% after B-TURP
Elsaqa et al.44 2023	Comparison of urethral stricture incidence between TURP and HoLEP	TURP	HoLEP	Urethral strictures were more frequent in TURP (4.2%) compared to HoLEP (1.9%). Functional outcomes favor HoLEP due to lower retreatment rates
Kaplan et al.47 2024	Retreatment rates and complications after BPH surgeries	TURP, HoLEP, PVP, UroLift, and others	-	Higher retreatment for US in TURP (1.2%) when compared with MISTs (PVP: 0.7%, Rezum: 0.3%, and Urolift: 0.4%) and PVP (0.7%)

BPH: benign prostate hyperplasia; HoLEP: holmium laser enucleation of the prostate; TURP: transurethral resection of the prostate; PVP: photovaporization of the prostate; B-TURP: bipolar-TURP; M-TURP: monopolar-TURP; US: urethral strictures; ThuLEP: thulium laser enucleation of the prostate; TUVP: transurethral vaporization of the prostate; MISTs: minimally invasive surgical techniques; -: none

Risk mitigation strategies

To reduce the risk of US, various strategies have been explored, including modifications in surgical techniques, instrument miniaturization, and improved perioperative management. The introduction of smaller endoscopes in procedures like MiLEP aims to limit urethral trauma.24,25 In 2023, Taha et al.24 tested this rationale in a propensity score-matched analysis comparing the surgical outcomes of MiLEP using a 22-Ch endoscope and HoLEP with a 26-Ch endoscope. The authors reported a reduced need for meatal dilatation in the MiLEP group (25% vs 78%, P = 0.01) and found no differences in the effectiveness of prostatic enucleation, operative time, hospital stay, complications, and improvements in the IPSS and quality of life score.24 In addition, reducing operative time and avoiding excessive energy application may minimize thermal injury.39

Postoperative strategies such as early catheter removal and antibiotic prophylaxis to prevent UTIs may further reduce the risk.40 Tao et al.40 identified intraoperative urethral mucosal rupture and prolonged bacterial colonization (positive urine test persisting over 6 weeks after removal of the catheter) as independent risk factors for anterior strictures post-TURP, suggesting that infection control is crucial.

The use of novel surgical technologies like Aquablation and UroLift, which do not involve thermal energy, represents another promising approach for reducing US incidence.45,46

Summary

US remains a significant complication following BPH surgery, with incidence rates ranging from 1% to 10%.30,31 Despite advancements in surgical techniques, the risk remains largely unchanged. Multiple factors contribute to US development, including mechanical trauma, thermal injury, prolonged surgery, and postoperative complications such as UTIs and catheterization.33,34,35,36,37,38,39,40 Instrument size appears to be a key determinant, with larger resectoscopes increasing the likelihood of strictures.35 While MISTs show promise in reducing US rates, they also carry a higher retreatment risk.45,46,47 Future efforts should focus on refining surgical approaches, minimizing urethral trauma, and optimizing postoperative care to mitigate the incidence of urethral strictures following BPH surgery.

BLADDER NECK STENOSIS (BNS)/BLADDER NECK CONTRACTURE (BNC)

Incidence and risk factors

Iatrogenic BNS is a well-known late complication in urological surgery, traditionally associated with TURP but common to all transurethral procedures, with an overall incidence ranging from 0.14% to 9.6%.48 Pansadoro and Emiliozzi49 conducted a notable study on the anatomical changes in the prostatic fossa following surgical treatment for LUTS/BPH. They identified three distinct types of strictures: type I, referred to as BNC proper, involves fibrous tissue affecting only the bladder neck, significantly restricting urinary outflow; type II, known as prostatic fossa sclerosis, is characterized by a stricture localized to the central part of the prostatic fossa; and type III involves a stricture extending throughout the entire prostatic urethra.49 Over the years, numerous authoritative studies have conclusively demonstrated that prostate gland size plays a significant role in the risk of developing BNC after transurethral surgery for LUTS/BPH.50,51,52,53,54,55

Recently, a retrospective study conducted by Goßler et al.50 comprehensively analyzed the potential risk factors associated with BNC after TURP. The study examined 1368 patients who underwent TURP, with 88 (6.4%) patients developing postoperative BNC requiring additional surgical intervention.50 No significant differences were found between patients with and without BNC regarding age, body mass index (BMI), hemoglobin levels, inpatient stay duration, medication use, diabetes prevalence, or history of radiotherapy.50 However, patients with BNC had significantly smaller preoperative prostate volume (P = 0.001), lower resected prostate weight (P = 0.004), lower preoperative prostate-specific antigen (PSA) levels (P < 0.001), and shorter surgical duration (P = 0.027).50 Additionally, these patients more frequently required further surgical treatment for severe hematuria or urinary retention (P = 0.018) and had a higher incidence of positive preoperative urine cultures (≥100 colony-forming units [CFU] per ml; P = 0.010).50

US requiring direct vision internal urethrotomy (DVIU) post-TURP was significantly associated with the development of BNC (P < 0.001), particularly strictures at the urethral sphincter (P = 0.046) and bulbar strictures (P < 0.001).50 Preoperative antibiotic treatment showed a significant protective effect (P = 0.042), especially with oral fluoroquinolones (P = 0.042).53 The median time from TURP to bladder neck resection (BNR) was 286.5 days, with 62.5% of patients requiring BNR within the 1^st year and 10.2% requiring BNR more than 2 years after the initial TURP.50 Similarly, Wu et al.51 retrospectively analyzed surgical outcomes of 1008 BPH patients who underwent transurethral prostate surgery between January 2017 and January 2022. A total of 2% (20/1008) of BPH patients developed BNC postoperatively, with a median occurrence time of 5.8 months.51 The incidences of BNC were particularly 4.7% and 1.3% in patients who underwent B-TURP and TUEP, respectively. Preoperative UTI, elevated PSA, smaller prostate volume, bladder diverticulum (BD), and B-TURP were significantly associated with BNC in the univariate analysis.51 Further multivariate logistic regression demonstrated preoperative UTI (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 2.25–17.42, P < 0.001), BD (OR: 7.40, 95% CI: 1.83–31.66, P < 0.001), and B-TURP (OR: 3.97, 95% CI: 1.55–10.18, P = 0.004) as independent risk factors.51

In addition, preoperative comorbidities and smoking history are potential risk factors for BNC. Chen et al.52 found that chronic kidney disease (P = 0.007) and cerebrovascular accidents (P = 0.01) were associated with increased BNC risk. Finally, the presence of ≥2 comorbidities was a significant risk factor (P = 0.001), indicating a possible correlation between microvascular disease and BNC.52

Mechanistic insight

The precise mechanisms underlying BNS following are not yet fully understood. Several factors have been suggested, including excessive resection of the bladder neck, overuse of electrocautery at this site, and the use of a large resecting loop that generates excessive heat, leading to the formation of hypertrophic scar tissue in small intraurethral adenomas.50,51,52,53,54,55 In particular, a slow resection speed/enucleation has been linked to unfavorable surgical outcomes such as hemorrhage, poor endoscopic visibility, prolonged operative time, and perforation of the prostatic fossa or bladder neck.52 In such cases, meticulous and extensive hemostasis may increase the risk of thermal injury to the bladder neck, ultimately raising the likelihood of scarring. A study found that patients who developed BNC after TURP had a significantly lower resection speed compared to those who did not (OR: 0.002, 95% CI: 0.001–0.94, P = 0.048).52

Furthermore, long-term or recurrent postoperative UTIs have been identified as independent predictors of BNC.52 These infections trigger a cascade of events, leading to fibrous scar formation at the bladder neck. Specifically, UTIs can cause urethral mucosal edema, exudation, excessive hyperplasia of granulation tissue, local tissue fibrosis, blood clot polarization, and inflammatory adhesion, all of which may ultimately result in BNC.50,51,52,53,54,55

Microvascular disease is another potential contributor to BNC due to its impact on tissue healing and local blood supply. Conditions such as diabetes mellitus, coronary artery disease, cerebrovascular disease, hypertension, chronic kidney disease, and a history of smoking can impair microvascular circulation in the bladder neck.50,51,52,53,54,55 When combined with local ischemia and surgical trauma, these factors may increase the risk of scar formation.

Among the late complications, BNS can be particularly troublesome and recurrent, often leading to urinary retention and necessitating multiple invasive procedures. This not only affects the patient’s quality of life but also undermines the intended benefits of the initial surgery.53

Technique-specific impacts

Rassweiler et al.55 analyzed post-operative complications following TURP, revealing that while short-term complications have decreased over the years, long-term issues such as BNS have remained stable, with an incidence rate ranging from 0.3% to 9.2%. A recent meta-analysis by Castellani et al.,54 which reviewed 26 randomized controlled trials, found that TURP was associated with a higher, though not statistically significant, rate of BNS compared to laser enucleation (relative ratio [RR]: 1.75, 95% CI: 0.81–3.79, P = 0.16). A sub-analysis confirmed a similar BNS incidence between M-TURP and enucleation (RR: 1.12, 95% CI: 0.39–3.21, P = 0.84),51 while B-TURP showed a higher BNS incidence compared to enucleation (RR: 2.93, 95% CI: 0.94–9.06, P = 0.06).54

To further reduce morbidity in BPH treatment, several endoscopic techniques have been developed.2 Among these, HoLEP, thulium laser enucleation of the prostate (ThuLEP), and PVP have been the most extensively studied.2 A meta-analysis by Cornu et al.3 found no significant differences in BNS rates among various energy modalities, including M-TURP, B-TURP, HoLEP, and PVP.

In 2021, Chen et al.52 analyzed data from 2363 patients who underwent TURP and 1656 who received ThuLEP. Among these, 62 developed BNC (with an average time to diagnosis of 21.3 months) and were matched to 124 controls without BNC using a 1:1 propensity score matching model.52 Multivariate analysis identified smaller prostate volume (OR: 0.96, P = 0.008) and the need for recatheterization (OR: 5.6, P = 0.047) as significant risk factors for BNC.52 Additionally, a prostate volume of less than 42.9 cm³ was strongly associated with a higher BNC rate.52 The propensity score matching model found no significant difference in BNC incidence between the resection and enucleation groups (1.7% for TURP vs 1.6% for ThuLEP).52 HoLEP has become increasingly popular for managing LUTS due to BPH; however, it has a steep learning curve and requires surgical expertise to minimize complications.2 The incidence of post-operative BNS, with a follow-up up to 5 years, following HoLEP ranges from 0.6% to 5.4%2 and is significantly associated with smaller gland size,56 whereas HoLAP has reported BNS rates ranging from 0.7% to 7%.56 A randomized study comparing HoLEP and M-TURP found no significant difference in BNS incidence at 36-month follow-up (3.1% for HoLEP vs 3.3% for M-TURP, P = 1.0).57 Conversely, Gu et al.58 followed 280 patients over 72 months and reported a lower BNS incidence in the HoLEP group (0) compared to the B-TURP group (1.3%). Similarly, Elkoushy et al.59 analyzed 1216 procedures with a median follow-up of 7.6 years, noting that 52 (4.3%) patients required repeat procedures for recurrent LUTS, of whom only 14 (1.1%) were diagnosed with BNC. These findings suggest that BNC occurrence following HoLEP is relatively low. A recent review by Gill et al.60 reported similar BNS rates between PVP and TURP (12.4% vs 11.5%, respectively). Additionally, data from the multicenter randomized noninferiority trial of GreenLight XPS Laser System (GL-XPS) with TURP for efficacy and safety (GOLIATH) showed no statistically significant differences in BNS rates between PVP and TURP at 2-year follow-up.61

Over the past decade, several emerging technologies, including Aquablation therapy, Rezum, and UroLift, have shown promising safety and efficacy profiles.2,45 However, robust data on BNS rates associated with these technologies remain limited. This lack of evidence may suggest a lower risk of BNS, though future studies are needed to confirm this hypothesis.4,45 In the pivotal study on the UroLift System, no additional surgical interventions for BNC were required over the first 5 post-operative years.62 In contrast, a study with a 4-year follow-up of 136 patients treated with Rezum reported a single case of BNC occurring 6 months post-procedure.9 Lastly, Gilling et al.10 found no significant difference in post-operative BNC incidence between TURP and Aquablation after 3 years of follow-up.

Risk mitigation strategies

Based on the data examined so far, the most significant risk factor for the development of BNC is small prostate volume, which is an inherently non-modifiable condition. Therefore, it is crucial to provide appropriate preoperative counseling for these patients with smaller prostate volume, informing them of their higher risk of BNC compared to the general population. Furthermore, as Orandi63 recognized in 1973, transurethral incision of the prostate (TUIP) should be considered as a therapeutic alternative to TURP in patients with small prostate glands whenever feasible.

Another key finding from the studies is the role of UTIs in the perioperative period. To minimize this risk, urinalysis and expressed prostatic secretions testing should be performed before surgery.2 Preventive measures should be taken to reduce the likelihood of postoperative UTIs. Additionally, patients diagnosed with moderate-to-severe prostatitis, either based on pathology or recurrent/persistent UTIs, should receive active treatment before undergoing surgery.52

The role of preserving the bladder neck during transurethral surgery remains a topic of debate. Some authors suggest that a prophylactic incision of the bladder neck using a bipolar loop or laser at the end of surgery may reduce BNC incidence.40 However, other studies indicate that excessive resection of the bladder neck can lead to hypertrophic scar formation and increase the risk of BNC.52

Lastly, limited to the use of thulium as an energy source, there would appear to be an advantage of enucleation techniques compared to ablation in terms of reducing the risk of BNC. A randomized controlled trial found that ThuLEP significantly lowered the risk of BNC compared to thulium vaporization of the prostate (ThuVap),64 as shown in Table 3.

Table 3.

Studies on transurethral lower urinary tract symptoms/benign prostate hyperplasia surgery, focusing on postoperative bladder neck contracture

Study	Brief description of the study	Intervention	Comparison	Key findings (focus on bladder neck contracture)
Pansadoro and Emiliozzi49 1999	Classification and endoscopic treatment of iatrogenic prostatic urethral strictures	Various	-	BNC incidence after TURP: 9%, managed endoscopically with a success rate of 85%
Goßler et al.50 2023	Risk factors for BNC after TURP	TURP	-	BNC incidence: 4.8%. Risk factors: prostate size <30 g (P=0.046); positive preoperative urine culture (P=0.021), and US requiring DVIU after TURP (P<0.001). Preoperative antibiotic treatment showed a protective effect (P=0.042)
Wu et al.51 2024	Retrospective study on BNC following TURP	TURP	-	BNC incidence: 5.3%. Significant risk factors: preoperative UTI (OR: 4.04, P<0.001), BD (OR: 7.40; P<0.001), and B-TURP (OR: 3.97; P=0.004) as independent risk factors
Chen et al.52 2021	Analysis of BNC risk factors post-TURP	TURP	-	BNC incidence: 6.2%. Significant risk factors: history of cerebrovascular accidents (P=0.009), coronary artery disease (P=0.03), chronic kidney disease (P=0.01), and two or more comorbidities (P=0.001) compared with no-BNC patients. Multivariate analysis showed that smaller prostate volume (OR: 0.96; P=0.008) and recatheterization (OR: 5.6; P=0.047) were significantly associated with BNC. A ROC curve predicted that a prostate volume <42.9 cm3 was associated with a notably higher rate of BNC
Lee et al.53 2005	A comprehensive study on BNC after TURP	TURP	TURP plus TUIP	BNC incidence: 9.7%. The incidence of BNC in the TURP group was greater than that in the TURP plus TUIP group (12.3% vs 6%; P<0.001)
Castellani et al.54 2021	Systematic review/meta-analysis of BNC after TURP	TURP, HoLEP, and PVP	-	The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation, and 1.2% after Ablation. The incidence of BNS was higher after TURP than after enucleation, but the difference was not statistically significant (RR: 1.75; P=0.16). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR: 1.31; P=0.26)
Rassweiler et al.55 2006	TURP complications: incidence and prevention	TURP	-	BNC incidence: (0.3%–9.2%). Prevention strategies: careful hemostasis, avoiding deep resection
Reich et al.56 2006	Long-term outcomes of TURP and alternative surgeries	TURP, and HoLEP	-	BNC incidence: TURP (6%), HoLEP (2.5%), favoring HoLEP for reduced BNC rates
Ahyai et al.57 2007	3-year RCT comparing HoLEP vs TURP	HoLEP	TURP	Similar BNC incidence across the groups: 3.1% vs 3.3% (P=1.0)
Gu et al.58 2018	6-year comparison of HoLEP vs B-TURP	HoLEP	B-TURP	BNC incidence: HoLEP (0) vs B-TURP (1.6%), favoring HoLEP
Elkoushy et al.59 2015	Reoperation rates after HoLEP for BPH	HoLEP	-	BNC requiring reoperation: 1.15%, often within 1st year post-surgery. BNC was significantly associated with smaller glands (<54 cm3)
Gill et al.60 2024	Meta-analysis of complications: GreenLight laser vs TURP	PVP	TURP	No differences in BNC incidence: PVP (2.9%) vs TURP (2.9%)
Thomas et al.61 2016	2-year outcomes of GreenLight-XPS laser vs TURP	GreenLight-XPS	TURP	PVP provided BNC incidence, efficacy, and safety outcomes similar to TURP
Roehrborn et al.62 2013	L.I.F.T. study: prostatic urethral lift for LUTS	UroLift	-	BNC incidence: 0.5%, significantly lower than TURP
Sun et al.64 2019	1-year outcomes of ThuLEP vs ThuLRP	ThuLEP	ThuLRP	No significant differences between the ThuLEP and ThuLRP groups in functional outcomes. ThuLRP group showed a significantly higher rate (13.6%) of BNC than the ThuLEP group (1.8%; P=0.045)

LUTS: lower urinary tract symptom; BPH: benign prostate hyperplasia; HoLEP: holmium laser enucleation of the prostate; TURP: transurethral resection of the prostate; PVP: photovaporization of the prostate; B-TURP: bipolar-TURP; BNC: bladder neck contracture; UTI: urinary tract infection; ThuLEP: thulium laser enucleation of the prostate; TUIP: transurethral incision of the prostate; DVIU: direct vision internal urethrotomy; -: none; OR: odds ratio; RR: relative ratio; ROC: receiver operator characteristic; BD: bladder diverticulum

Summary

BN remains a significant long-term complication of TURP and other transurethral procedures, with incidence rates ranging from 0.14% to 9.6%.54 Contributing factors include prostate size, perioperative UTIs, surgical duration, and thermal injury.50,51,52,53,54,55 Emerging transurethral techniques, such as laser enucleation and MISTs, have demonstrated comparable or lower BNS rates than TURP. Future efforts should focus on refining surgical techniques, minimizing thermal damage, and optimizing perioperative care to reduce the risk of bladder neck stenosis.

PERSISTENT/DE NOVO POST-OPERATIVE LUTS AND REINTERVENTION

Incidence and risk factors

The primary goal of transurethral surgery for BPH is to alleviate or eliminate LUTS. However, post-surgical worsening of both storage and voiding LUTS is well documented.65 Age and preoperative LUTS significantly influence the persistence or recurrence of symptoms, with advanced age strongly correlating with continued detrusor overactivity.65,66 Anatomical characteristics, including prostate size, transitional zone index (TZI), intravesical prostatic protrusion (IPP), and prostatic urethral angulation (PUA), also impact outcomes.67,68 A greater PUA is associated with improved postoperative IPSS, maximum urinary flow rate (Qmax), and post-void residual (PVR), particularly in prostates smaller than 50 ml.68 Patients with high TZI may respond better to interventions reducing transition zone volume.68 Conversely, IPP exacerbates urinary obstruction by affecting bladder neck dynamics and functioning as a valve-like mechanism.67

Metabolic syndrome and smoking increase the risk of persistent moderate-to-severe nocturia, regardless of anatomical factors.69 More broadly, frailty is a key predictor of poor functional outcomes post LUTS/BPH surgery.69

Mechanistic insight

It is crucial to differentiate new-onset LUTS due to surgical technique from those arising as complications. Energy release, particularly in the form of heat, correlates with irritative/storage symptoms, though no specific energy source has been identified as riskier.70 Excessive energy discharge can cause thermal insult, while irritative/storage symptoms are more often linked to preoperative prostate volume, functional bladder disorders, and the severity of preoperative LUTS.70 In laser enucleations, extreme angular movements and mechanical stress on the external urinary sphincter can lead to transient urinary incontinence.71

Postoperative complications, such as UTIs, US, and BNC, are significant contributors to new-onset LUTS.2 UTIs occur in 27% of patients receiving adequate antibiotic prophylaxis and up to 47% with inadequate prophylaxis.72 Post-surgery US develops in 4.5%–13% of patients and accounts for 41% of iatrogenic cases.31 BNC affects 0.3%–9.7% of patients undergoing LUTS/BPH transurethral procedures, further contributing to de novo LUTS development.31

Technique-specific impacts

The medication discontinuation rate serves as a strong indicator of surgical success. Following laser enucleation, 85% of patients discontinue medical therapy within 6–12 months, compared to 86% for TURP and 98.6% for simple prostatectomy. At 12 months, these rates decline to 52.9%, 62%, and 87.3%, respectively.73 Techniques that rely on tissue necrosis rather than removal tend to yield poorer and less durable outcomes.73,74

Despite significant LUTS improvements following BPH surgery, a subset of patients experience persistent or new-onset symptoms, necessitating further interventions.75 Success and durability can be measured by the absence of pharmacological therapy and the lack of reoperation. A study by Ditonno et al.75 analyzing data from 274 808 patients over a decade found that TURP remained the most common procedure (71.7%). While traditional procedures dominated (87.8%), MISTs increased despite being 1.43 times more expensive. The overall surgical reintervention rate was 9.4%, with a mean time to reoperation of 25.3 months, 85.5% occurring within 5 years.75 Techniques such as TUIP, PVP, UroLift, and Rezum exhibited higher reintervention rates than TURP. In contrast, HoLEP/ThuLEP and simple prostatectomy had lower reoperation rates75 (Table 4).

Table 4.

Studies on transurethral lower urinary tract symptom/benign prostate hyperplasia surgery, focusing on postoperative de novo lower urinary tract symptom, and retreatment rate

Study	Brief description of the study	Intervention	Comparison	Key findings (focus on retreatment and de novo LUTS)
Kim et al.65 2018	Review of LUTS post-TURP	TURP	-	20%–50% patients have persistent LUTS following TURP
Antunes et al.66 2015	Predicting resolution of detrusor overactivity after TURP	TURP	-	Advanced age together with low maximum cystometric capacity, and early and high detrusor over activity amplitude are the most important predictors of persistent detrusor overactivity
Ku et al.67 2010	Correlation between prostatic urethral angle and BOOI	-	-	Higher prostatic urethral angles correlated with greater BOOI and a higher likelihood of persistent LUTS post-TURP
Kaplan et al.68 1995	Transition zone index as a predictor of BPH severity	-	-	Higher transition zone index (ratio between transition zone volume and prostate volume) was associated with increased obstruction severity and a higher probability of requiring retreatment
De Nunzio et al.69 2019	Impact of MetS and smoking on nocturia persistence post-TURP	TURP	-	After TURP, moderate/severe nocturia was reported in 42% of the patients. On multivariate analysis, prostate volume, MetS, and smoking were independent risk factors for moderate/severe persistent nocturia after TURP
Khawcharoenporn and Kanoktipakorn72 2022	Effectiveness of antibiotic prophylaxis in TURP	TURP	-	Lower incidence of post-TURP UTI among patients receiving appropriate antibiotic prophylaxis versus inappropriate antibiotic prophylaxis (27% vs 47%; P<0.001). Preoperative urine culture is critical for post-TURP UTI prevention
Sabharwal et al.73 2019	Comparative effectiveness of TURP and other procedures on medication discontinuation	TURP	Various procedures	TURP and laser prostatectomy were associated with significantly higher medication discontinuation rates and lower resumption and initiation rates compared to tissue necrosis procedures
Campbell and Gill74 2020	Medication discontinuation as a measure of TURP effectiveness	TURP	Various procedures	Rates of BPH/LUTS medication use after TURP varied from 15% to 55%, and discontinuation rates were 54%–95%. For laser prostatectomy, approximately 18% of patients continued medications postoperatively and discontinuation rates ranged from 53% to 75%.Medication discontinuation rates after transurethral needle ablation or microwave therapy were only 15%–28%
Ditonno et al.75 2024	Trends, costs, and retreatment rates for BPH surgeries in the USA	Various BPH surgeries	-	Surgical retreatment rate was 9.4%. The mean time to surgical retreatment was 25.3 months. At the multivariable analysis, TUIP, PVP, Urolift, Rezum, and PAE had a significantly greater likelihood of surgical retreatment than TURP. HoLEP/ThuLEP, simple prostatectomy were associated with a lower probability of resurgery than TURP, but a similar probability between these procedures

LUTS: lower urinary tract symptoms; BPH: benign prostate hyperplasia; HoLEP: holmium laser enucleation of the prostate; TURP: transurethral resection of the prostate; PVP: photovaporization of the prostate; B-TURP: bipolar-TURP; M-TURP: monopolar-TURP; TUIP: transurethral incision of the prostate; ThuLEP: thulium laser enucleation of the prostate; GreenLEP: GreenLight laser enucleation of the prostate; PAE: prostate artery embolization; SP: simple prostatectomy; IPSS: International Prostate Symptoms Score; IIEF: International Index of Erectile Function; UTI: urinary tract infection; MetS: metabolic syndrome; BOOI: Bladder Outlet Obstruction Index; -: none

Risk mitigation strategies

Persistent LUTS after BPH surgery is strongly influenced by preoperative symptom severity and metabolic health. Optimal surgical timing and lifestyle modifications, particularly weight loss, can improve LUTS and reduce symptom persistence after invasive treatments.

As suggested in the previous paragraphs, to minimize new-onset LUTS due to surgical complications, strategies include appropriate energy application, reducing instrument caliber, and avoiding excessive traction on the sphincter and surrounding mucosa.

Summary

Transurethral surgery significantly improves LUTS, yet persistent or new-onset symptoms remain a concern, influenced by age, anatomical factors, and preoperative conditions. TURP and laser enucleation show high medication discontinuation rates. New-onset LUTS may result from procedural factors or complications such as UTIs and strictures. Lifestyle modifications and meticulous surgical techniques can mitigate risks, and reoperation rates serve as a critical long-term success metric.

LIMITATIONS

Analyzing complications associated with transurethral surgical techniques for LUTS/BPH is complex. The literature contains limited randomized comparative studies that specifically evaluate complications related to urethral manipulation. As a result, most available data come from studies primarily focused on clinical outcomes, rather than transurethral complication rates. Moreover, variations in follow-up duration across studies can influence the reported incidence of complications, making direct comparisons challenging. Dedicated studies on risk minimization strategies are even scarcer. Consequently, most recommendations in this area rely on observational analyses, rather than rigorous trials. To address these gaps, future research should prioritize studies that assess the incidence and nature of complications arising from transurethral approaches, as well as the effectiveness of risk mitigation strategies. Standardized methodologies and longer follow-up periods are essential to generate high-quality evidence in this field.

CONCLUSIONS

The transurethral approach in the surgical treatment of BPH is a true success story in urological surgery. By combining ease of access with minimal invasiveness and reduced blood loss, it enables effective endoscopic procedures and promotes early patient recovery. However, regardless of the specific transurethral technique used, postoperative complications, particularly those affecting the urinary sphincter and urethral mucosa, remain significant. This is especially concerning given the high prevalence of BPH surgeries in the aging population. These complications are often underestimated due to their delayed onset and the fact that the surgeon managing them is frequently not the one who performed the original procedure. Raising awareness of these potential complications allows urologists to adopt strategies to minimize their occurrence. Advances such as miniaturized instruments, more precise energy application, sphincter-sparing enucleation techniques, and the development of MISTs all contribute to a more refined and anatomically respectful transurethral approach.

AUTHOR CONTRIBUTIONS

BB provided concept and study design, performed data analysis, and drafted the manuscript. CG and FP performed data analysis and drafted the manuscript. LMG, EB, and LCL performed data collection and interpretation and drafted the manuscript. VA, OD, and TA performed data collection and drafted the manuscript. AC provided concept and study design and made a critical revision of the manuscript. FP, MM, and AC provided data interpretation and a critical revision of the manuscript. All authors read and approved the final manuscript.

COMPETING INTERESTS

All authors declare no competing interests.